An unprecedented year and how the traditional model of care of respiratory patients has changed by Fiona McDonald on 23rd September 2020
Joel D. Howel, in 2010 wrote an essay on the past and future of primary care (Albeit from an American perspective), but in it the synergies between war and consequential changes to healthcare practice are clearly articulated. 2020 has been a war, not a traditional war, but a global pandemic that has seen widespread change not only in the UK to the way healthcare is delivered, but across the world. It has forced us as a healthcare system to adapt and change at a pace those of us working in health informatics have been striving for since the early noughties! A price to pay maybe, but a driver non the less.
In 1923, W.B Saunders, described the ‘telephone as an instrument that is of equal importance to the stethoscope’ . The digitisation of healthcare has been one of the slower industries to adapt to technology, for a wide range of sociological, infrastructure, supplier market and cultural reasons.
In mid-March 2020 when ‘lock down’ was first introduced and primary care had to rapidly redesign itself, those at most risk (prior to evidence base becoming available) were thought to be among others, the elderly and particularly those with respiratory conditions such as asthma and COPD. This vulnerable group were sent communications to ‘isolate and shield’ for the following 3 months as a minimum.
How was general practice going to support and monitor those high-risk patients with a respiratory long-term condition in the current climate? All patients with asthma and COPD are traditionally offered an annual face to face review in general practice, often by the General Practice Nurse team and managed accordingly (with associated QOF incentives). Telephone appointments or video consultations started to be offered, but this was time consuming and provided no structured information prior to the consultation.
Across many areas the Asthma Control Test is widely used as a validated screening questionnaire for children aged 4-11 and age 12-adult, to assess the stability of the patients asthma control and provide structured information and directed areas to focus on for further treatment. This is often printed out and used as a guide for practitioners to assess their patients during the face to face consultation.
2020 Quality and Outcomes Framework GMS Contract.
|Indicator ID||Indicator Thresholds||Payment Thresholds|
|AST007||The percentage of patients with asthma on the register, who have had an asthma review in the preceding 12 months that includes an assessment of asthma control using a validated asthma control questionnaire, a recording of the number of exacerbations, an assessment of inhaler technique and a written personalised action plan.||45-70%|
|AST008||The percentage of patients with asthma on the register aged 19 or under, in whom there is a record of either personal smoking status or exposure to second-hand smoke in the preceding 12 months.||45-80%|
In the same way, the COPD CAT Test, or COPD Assessment Test, is used, printed out on paper and used as a tool for screening by healthcare teams. The Medical research Council Dyspnoea scale is also included in QOF.
|Indicator ID||Indicator Thresholds||Payment Thresholds|
|COPD010||The percentage of patients with COPD on the register, who have had a review in the preceding 12 months, including a record of the number of exacerbations and an assessment of breathlessness using the Medical Research Council dyspnoea scale.||50-90%|
|COPD008||The percentage of patients with COPD and Medical Research Council (MRC) dyspnoea scale ≥3 at any time in the preceding 12 months, with a subsequent record of an offer of referral to a pulmonary rehabilitation programme (excluding those who have previously attended a pulmonary rehabilitation programme).||40-90%|
In Mid-March 2020, these tools needed to be adapted into digital pathways so healthcare teams from general practice could triage, assess, and monitor this cohort of patients and rapidly signpost those with potential COVID symptoms, to the 111 online triage system. Healthcall worked closely with respiratory lead GP’s and General practice nurse leads. As well as the validated screening questionnaires, there were several other elements that were required for the digital pathway and clinical safety at this time:
- COVID-19 screening questions
- Previous admissions to hospital in the previous 12 months, including ICU.
- Previous use of steroid therapy in the previous 12 months
- Use of oxygen therapy in the previous 12 months
- Validated CAT and asthma control test
- MRC Dyspnoea scale (for the COPD questionnaire)
- Smoking status and
- Sign posting to self help sites
The pathways were developed and integrated into EMIS and S1 and launched from within the clinical systems. Patients details are uploaded onto the platform, (usually with admin support), spine validated for demographic accuracy and patients are sent either an SMS or email from their GP surgery, to register and complete the screening questionnaires. This is practice specific as to how they manage their caseload, but normally reflects the way traditional appointment reminders would be generated.
The COVID-19 symptom screening questions appear first, if any responses are positively indicated, the patient is immediate directed to the 111 online COVID triage service.
The screening questionnaires are automatically weighted accordingly by the system and a response message is sent to the patient depending on the outcome score. If the patient replied yes to any of the previous 12 months exacerbation questions or their score was below 19 for the asthma screening test or above 10 for the COPD CAT test, an automated message is sent back to the patient requesting they make a further online appointment with their healthcare team.
If the scores are satisfactory and no exacerbation indicators within the last 12 months, the patient receives a response message to continue with current treatment as their condition appears to be stable, but to contact the practice in the future should their condition deteriorate.
The information the clinician receives.
As well as the screening score for this episode of care, the information from the screening questionnaire is integrated back into the clinical record, and SNOMED coded for the clinician to view. See below:
It is important to manage your asthma well and reduce your risk of an asthma attack.
Managing your asthma means:
- You get no daytime symptoms
- You get no night-time waking due to asthma
- You don’t need to use your emergency reliever inhalers (usually blue)
- You don’t have any asthma attacks and don’t need emergency treatment
- Your lungs don’t suffer long-term damage
- Asthma doesn’t limit your daily life (including working and exercising)
To help us support you in managing your asthma, please complete the following questionnaire.
At the end of the questionnaire, there are some useful links to helpful websites. We also give you guidance on when to contact us, however if you have any questions about your asthma, please contact your practice for a telephone asthma review or visit one of our recommended websites.
If you need more information on whether you meet the criteria for sever asthma, please go to the Asthma UK website or contact your health centre.
The first two questions are to screen for Covid-19, to help you identify if you have any symptoms and what action you need to take.
Do you have a new continuous cough? No
New: means a cough that you’ve not had before, or if you usually have a cough it’s got worse.
Continuous: means coughing a lot, for more than an hour, or three or more coughing episodes in 24 hours.
Do you have a high temperature (fever)? No
You don’t need a thermometer or to know a precise temperature. If you feel hot to touch on your chest or back, answer ‘yes’.
Have you been admitted to hospital in the last 12 months for your asthma? True
Have you had 2 or more severe asthma attacks in the last 12 months, that is attacks attacks in which you have been given a course of oral steroids? False
Have you been admitted to an intensive care unit for your asthma? False
Select the age group for the patient this screening questionnaire is intended for: 12 years or older
Please answer these questions with a scale from 1-5:
In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or home? 3 – some of the time
During the past 4 weeks, how often have you had shortness of breath? 2 – once a day
During the last 4 weeks, how often did your asthma symptoms wake you up at night or earlier than usual? 3 – once a week
During the last 4 weeks, how often have you used your relief medication? 1 – three or more times a day
How would you rate your asthma control during the past 4 weeks? 1 – not controlled
Are you currently a smoker? No
If you need more information on whether you meet the criteria. for sever asthma, go to the Asthma UK website.
A similar set of results are integrated back into the clinical record for the COPD CAT questionnaire as well as the MRC Dyspnoea scale.
- For those patients that rarely respond to invitations for annual screening appointments, completing the questionnaire remotely is starting to increase, as they can complete the screening questionnaire at a time that is convenient for them. This is particularly prevalent in the young adult population, though further statistical analysis is required to validate this.
- Allows clinicians to have structured information and provides a focus on areas of treatment or educational techniques for those patients who require further follow up. This can reduce time spent for clinicians working in unfamiliar online communications.
- Provides an oversight of stability for the clinician and the ability to triage and target urgent follow up and treatment accordingly.
- Allows for comparison, providing insights into deterioration or improvement in treatment within the clinical record.
- Prevents unnecessary wasted face to face appointments for those patients whose treatment is stable, therefore providing more targeted healthcare for those patients that require it.
- As many patients with asthma are of working age, it allows appropriate healthcare screening without the need to seek time off work, find child care and reduces carbon footprint for those that do not need to attend a ‘building’.
- 4 million people in the UK are currently receiving treatment for asthma: 1.1 million children (1 in 11) and 4.3 million adults (1 in 12). Asthma can be a debilitating and serious condition, 200,000 people in England are thought to be in this category. Those that are stable, could be saving general practice considerable time in unnecessary face to face appointments, freeing up time for those that require more intensive consultation and treatment and providing more convenient access to healthcare for patients.
Is it time to rethink how we prioritise and screen patients in General practice? With the winter pressure season emerging and the concern of another peak in COVID-19 cases in the winter of 2020, with the possibility of a further 6 months of some sort of lock down and remote healthcare, we need to continue to provide healthcare for all patients in a smarter more efficient and time saving way!
If you require any further information about our respiratory screening tools please contact us at email@example.com